Wound Care

Fundamentals of Nursing Care, 2nd ed., Ch 26Objectives 1. Define various terms r/t wound care.2. Contrast contusion, abrasion, puncture,

penetrating, & LAC wounds, & pressure ulcers.

3. Correctly stage pressure ulcers.4. Compare 1st, 2nd, 3rd, intention wound

closures.

Terminology Related to Wound Healing

• Dehiscence: Partial or complete separation of outer wound layers

• Evisceration: The rupturing of a wound• Eschar: Hard, dry, leathery dead tissue• Granulation tissue: New tissue that

grows & fills in a wound• Sinus tract: Tunnel that develops

between 2 cavities or between an infected cavity & the skin’s surface

Wound Conditions

• Edema: Swelling• Erythema: Redness• Necrotic: Dead tissue• Ischemia: Reduced blood

flow• Purulent: Containing pus

Classifications of Wounds

General Wounds• Contusions• Abrasions• Puncture wounds• Penetrating

wounds• Lacerations

Other Wounds Commonly Found in Hospitalized Pts

• Stasis ulcers• Sinus tracts • Surgical incisions

Categories of Wound Contamination

• Clean: Not infected • Clean-contaminated: Has direct

contact with normal flora & potential for infection

• Contaminated: Grossly contaminated by breaking asepsis

• Infected: Infectious process established

• Colonized: High # of microorganisms present without signs of infection

Risk Factors for Pressure Ulcer Development

• Being elderly• Being emaciated or malnourished• Being incontinent of bowel or

bladder• Being immobile• Having impaired circulation or

chronic metabolic conditions

Stage of Pressure Ulcers• Deep tissue injury: Area over a bony

prominence that differs from surrounding tissue; may be blister-like or a discoloration

• Stage I: Erythema• Stage II: Partial-thickness loss of dermis• Stage III: Full-thickness loss; damage to

epidermis, dermis, & subcutaneous tissue• Stage IV: Full-thickness loss; damage to

deep tissue, muscle, fascia, tendon, joint capsule, and/or bone

• Unstageable: Eschar covers the wound, making it impossible to tell the depth

Assessment Parameters: Pressure Ulcers

• Pallor: Related to impaired circulation

• Erythema: Increased capillary blood flow due to inflammation

• Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity

• Bruising: Note any discolored areas that are found to determine if new breakdown occurs

Assessment Parameters: Pressure Ulcers

• Pallor: Related to impaired circulation

• Erythema: Increased capillary blood flow d/t inflammation

• Jaundice: High serum level of bilirubin; skin is more susceptible to loss of integrity

• Bruising: Note any discolored areas that are found to determine if new breakdown occurs

3 Phases of Wound Healing

• Inflammatory –Occurs when the wound is fresh;

includes both hemostasis & phagocytosis

• Reconstruction (proliferation) –Occurs when the wound begins to

heal, about 21 days after injury• Maturation (remodeling)

–Occurs when the wound contracts & the scar strengthens

Types of Wound Closures for Healing

• First intention– Wound is clean with little tissue loss,

edges are approximated, & wound is sutured closed

• Second intention– There is greater tissue loss, wound edges

are irregular, & wound is left open• Third intention

– Wound is left open for some time to form granulation tissue & then sutured closed

Complications of wound healing

Slough: thin, mucous-like substance, loose stringy necrotic tissue; yellow or brown/gray-green

Necrotic: dead, a vascular tissue which is black.

Eschar: Devitalized tissue which is black, thick & leathery.

Factors Affecting Wound Healing

• Age• Chronic illness• Diabetes

mellitus• Hypoxemia• Lifestyle

choices• Lymphedema

• Medications• Multiple wounds• Nutrition &

hydration• Radiation exposure• Wound tension

Complications of Wound Healing & Nursing Responses

• Infection: – Inspect & assess wounds every 8

hours; notify physician of findings of infection

• Hemorrhage: –Notify physician immediately; place

in Fowler’s position with knees flexed; apply pressure to bleeding; administer oxygen

Complications of Wound Healing & Nursing Responses

Cellulitis• Inflammation of tissue surrounding

wound characterized by redness & induration

Fistula• An abnormal passage btw. 2 organs or

an internal organ & body surface

Sinus• A canal or passageway leading to an

abscess

Complications of Wound Healing & Nursing Responses

Dehiscence: spontaneous opening of incision

• sign of impending dehiscence: –↑ flow of serosanguineous drainage

Evisceration: protrusion of internal organ through incision

• Wound dehiscence & evisceration: –Place patient in supine position; notify

physician; react to evisceration immediately

Signs of Wound Infection

• Redness or increased warmth• Swelling• Wound drainage• Unpleasant smell• Pain around wound• Fever above 100°F

Débridement

Process of removing necrotic tissue from a wound so that healing can occur.

Wound Treatments

• Débriding a wound• Sharp• Mechanical• Enzymatic• Autolysis

Wound Treatments• Wound cleansing— warmed

isotonic saline• Antibiotic solutions may be ordered

for wound irrigation• Surgical wounds & open wound

dressing require sterile technique. • May require hydrocolloid or wet-to-

dry dressings

Wound Treatments–Sutures & staples for closure

• Large retention sutures• Dermabond: a synthetic glue

Nursing Care • Assessment of sutures every 8 hours

–Note loosening, gaps, and redness• May be responsible for removing

suture/staples when the wound is healed

Types of Drains

• Hemovac: Active drain uses suction

• Jackson-Pratt: Active drain uses suction

• T-tube: Passive drain uses gravity

• Penrose: Open drain; not commonly used because can provide pathway for pathogens

Wound Drainage

• Sanguineous• Serous• Purulent• Bilious• Serosanguineous• Seropurulent

Wound Assessment

• Site• Wound type• Wound closure• Condition of wound bed• Condition of skin surrounding

wound• Pain • Drainage

Purposes of Dressing

• Protect the incision• Absorb drainage as the wound

heals• Protect the wound from further

injury• Provide moist environment for

healing• Fill the open space within the

wound

Types of Dressings

• Antimicrobial with silver or dacexomer

• Alginate• Gauze• Foam dressings• Honey-impregnated dressings• Hydrocolloid• Hydrogel• Negative pressure wound therapy• Transparent films

Types of Dressings

• Stage I: Thin film dressings used to protect ulcers from shear

• Stage II noninfected— hydrocolloid dressing

• Stage III draining ulcers— absorbent dressing

• Infected ulcers—nonocclusive

• Negative pressure treatment may ↑ healing rate by 40%.

–Uses a device known as vacuum-assisted closure

–Removes fluid from wound, allows penetration of fresh blood

–Keeps wound moist

Types of Dressings

Securing Dressing & Tape Application

Dressing may be secured with•Stretch gauze (Conform, Kerlix, Kling)

•Mesh netting•Elastic bandage•Montgomery straps•Binders•Tape

Protein & Wound Healing

• Protein intake is required for wounds to heal.

• Patients who are tube fed may not get enough protein & calories which slows wound healing.

Wound Documentation

• Amount & color of drainage on old dressing

• Length, width, diameter, & depth of wound

• Sinus tracts & their length• Color of wound • Appearance of surrounding skin• Type of dressing applied

Nursing Care Plan for a Pressure Ulcer

• Assess the wound • Assess nutritional status of pt• Assess pt risk factors• Analyze data & make nursing

diagnoses• Plan appropriate interventions• Implement & evaluate interventions

Nursing Care Plan for a Pressure Ulcer

• Focused skin assessment• Braden scale

• Numeric value for 6 risk factors related to impaired skin integrity

• Total score <18 = risk

Nursing Care Plan for a Pressure Ulcer

Determine stage:• Stages I–IV: classified by tissue

involvement• Stages III & IV: involve tissue

necrosis

Nursing Interventions

• Prevention• Meticulous skin care• Adequate nutrition• Frequent repositioning• Therapeutic mattresses• Client/family teaching